Kin 191 B – Elbow And Forearm Pathologies


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  • Kin 191 B – Elbow And Forearm Pathologies

    1. 1. KIN 191B – Advanced Assessment of Upper Extremity Injuries Elbow and Forearm Pathologies
    2. 2. Patholgies <ul><li>Elbow ligamentous sprains </li></ul><ul><li>Epicondylitis </li></ul><ul><li>Rupture of distal biceps brachii tendon </li></ul><ul><li>Osteochondritis dissecans of capitellum </li></ul><ul><li>Neurological injury </li></ul><ul><li>Elbow dislocations </li></ul><ul><li>Fractures </li></ul><ul><li>Olecranon bursitis </li></ul>
    3. 3. Elbow Ligamentous Sprains <ul><li>Medial (ulnar) collateral ligament injury </li></ul><ul><li>Lateral (radial) collateral ligament injury </li></ul>
    4. 4. MCL/UCL Injury <ul><li>Can be acute (traumatic valgus force) or chronic (e.g. - repetitive overhand throwing) </li></ul><ul><li>Anterior bundle most affected – primary stabilizer </li></ul><ul><li>Posterior bundle may be involved if elbow flexed beyond 60 degrees at time of injury </li></ul>
    5. 5. MCL/UCL Injury <ul><li>Most common symptoms include: </li></ul><ul><ul><li>Point tenderness, swelling (may be significant), neuro symptoms (ulnar and radial nerves), limited elbow and forearm ROM due to tension on ligaments and pain, laxity to valgus stress test </li></ul></ul><ul><li>Mild and moderate injuries often treated conservatively with rest, NSAIDs, progressive flexibility and strengthening exercises </li></ul><ul><li>Severe injuries, especially in competitive athletes, typically treated surgically </li></ul><ul><ul><li>“ Tommy John” injury/surgery </li></ul></ul><ul><ul><li>Usually use palmaris longus tendon as graft </li></ul></ul>
    6. 6. LCL/RCL Injury <ul><li>Much less common than MCL/UCL injury </li></ul><ul><li>When occur, typically due to varus force application – may injure LCL/RCL and annular ligament </li></ul><ul><ul><li>May affect radial articulation with capitellum and/or proximal radioulnar articulation </li></ul></ul><ul><li>Most common symptoms include: </li></ul><ul><ul><li>Point tenderness, swelling, limited elbow and ROM and laxity to varus stress test </li></ul></ul><ul><li>Almost always treated conservatively </li></ul>
    7. 7. Epicondylitis <ul><li>Medial epicondylitis </li></ul><ul><ul><li>Commonly referred to as “golfer’s elbow” </li></ul></ul><ul><ul><li>May present as “little leaguer’s elbow” </li></ul></ul><ul><li>Lateral epicondylitis </li></ul><ul><ul><li>Commonly referred to as “tennis elbow” </li></ul></ul>
    8. 8. Medial Epicondylitis <ul><li>Irritation of medial epicondyle from overuse of pronation and flexion muscles </li></ul><ul><li>May irritate ulnar nerve if significant – most common presentation is point tenderness, swelling at site and weakness to affected muscles </li></ul>
    9. 9. Medial Epicondylitis <ul><li>“ Little leaguer’s elbow” is avulsion of flexor/pronator common tendon from origin at medial epicondyle </li></ul><ul><li>Typically treated conservatively with rest, NSAIDs, flexibility and strengthening exercise program </li></ul>
    10. 10. Lateral Epicondylitis <ul><li>Irritation of lateral epicondyle from overuse of supination/extension muscles </li></ul><ul><li>Most commonly involves extensor carpi radialis longus and brevis </li></ul><ul><li>Most common presentation is point tenderness, swelling at site and weakness to affected muscles </li></ul>
    11. 11. “ Tennis Elbow” Test <ul><li>Clinician palpates lateral epicondyle with elbow at 90 – resists extension of wrist </li></ul><ul><li>Positive if painful and/or weak at lateral epicondyle – ECRB involvement </li></ul><ul><li>If test replicated with elbow extended, indicates ECRL involvement </li></ul>
    12. 12. Rupture of Distal Biceps Tendon <ul><li>Etiology is eccentric loading of tendon with elbow extended (hyperextension) </li></ul><ul><li>Often accompanied by “pop” at elbow </li></ul><ul><ul><li>X-ray used to rule out avulsion fracture </li></ul></ul><ul><li>Visible/palpable defect present, typically has considerable swelling/ecchymosis to cubital fossa </li></ul>
    13. 13. Rupture of Distal Biceps Tendon <ul><li>AROM/PROM may be WNL but RROM limited to elbow flexion and forearm supination </li></ul><ul><li>Almost always treated surgically followed by progressive ROM and strengthening program </li></ul>
    14. 14. OCD of Capitellum <ul><li>Etiology is repetitive valgus loads at the elbow compressing radial head on capitellum – overhead throwing </li></ul><ul><li>Gradual vs. acute onset of symptoms </li></ul><ul><li>Typical complaints of lateral elbow pain which worsens with activity – often accompanied by elbow flexion contracture </li></ul>
    15. 15. OCD of Capitellum <ul><li>X-ray can reveal non-displaced defect or loose body in joint </li></ul><ul><li>If non-displaced, usually treated conservatively </li></ul><ul><li>If loose body, surgical removal is indicated </li></ul><ul><li>Atypical to return to prior activity and/or performance level </li></ul>
    16. 16. Neurological Injury <ul><li>Ulnar nerve </li></ul><ul><li>Median nerve </li></ul><ul><li>Radial nerve </li></ul><ul><li>Forearm compartment syndrome </li></ul><ul><ul><li>Volkmann’s ischemic contracture </li></ul></ul>
    17. 17. Ulnar Nerve <ul><li>Superficial orientation in cubital tunnel predisposes ulnar nerve to injury </li></ul><ul><li>May be contused via direct trauma, compressed by flexor/pronator mass, and/or sublux from cubital tunnel </li></ul><ul><li>Numbness/tingling to medial forearm, hand and ring/little fingers </li></ul><ul><li>Weakness to finger flexion, abduction and adduction </li></ul><ul><li>Evaluated with Tinel’s sign </li></ul>
    18. 18. Cubital Tunnel Syndrome <ul><li>General term given to ulnar nerve injury or irritation </li></ul>
    19. 19. Median Nerve <ul><li>Median nerve most commonly affected at wrist – may be compressed with pressure in cubital fossa </li></ul><ul><li>Branch of median nerve, anterior interosseous nerve, passes between heads of pronator teres – may be compressed there causing pronator teres syndrome </li></ul><ul><ul><li>Inability to pinch together tips of thumb and index finger </li></ul></ul>
    20. 20. Radial Nerve <ul><li>Rarely injured unless associated with laceration, fracture or dislocation </li></ul><ul><li>Sensory deficit to dorsal aspect of hand (1 st dorsal webspace) </li></ul><ul><li>Motor deficit to wrist/finger extension and supination </li></ul>
    21. 21. Forearm Compartment Syndrome <ul><li>Forearm compartments similar to leg </li></ul><ul><li>Increased pressure can occur from: </li></ul><ul><ul><li>Muscle hypertrophy, fractures, dislocations </li></ul></ul><ul><li>Neurovascular compromise can present with sensory and/or motor deficits – if severe, can present with decreased or absent radial and ulnar pulses </li></ul><ul><ul><li>Volkmann’s ischemic contracture – flexion contracture of wrist/hand/fingers </li></ul></ul>
    22. 22. Elbow Dislocations <ul><li>Posterior </li></ul><ul><li>Anterior </li></ul>
    23. 23. Posterior Elbow Dislocation <ul><li>Typically results from hyperextension, trochlea levered over coronoid process </li></ul><ul><li>Most common direction is posterolateral </li></ul><ul><li>Involve injury to most ligamentous structures, and potential for injury to neurovascular structures – if stable post-reduction, treat conservatively and if unstable, treat surgically </li></ul><ul><li>Most present with subsequent myositis ossificans </li></ul>
    24. 24. Posterior Elbow Dislocation
    25. 25. Anterior Elbow Disocation <ul><li>Rare occurrences </li></ul>
    26. 26. Fractures <ul><li>Humerus </li></ul><ul><li>Ulna </li></ul><ul><li>Radius </li></ul>
    27. 27. Humerus Fractures <ul><li>Supracondylar fracture </li></ul><ul><li>Supracondylar fracture with posterior elbow dislocation </li></ul>
    28. 28. Humerus Fractures <ul><li>Most common in children/adolescents from fall on flexed elbow or hyperextension mechanism </li></ul><ul><li>Deformity present if displaced, often missed on initial evaluation if nondisplaced </li></ul>
    29. 29. Ulnar Fractures <ul><li>Olecranon process fractures </li></ul><ul><ul><li>If stable/nondisplaced, short immobiliazation period (45-90 degrees of flexion) </li></ul></ul><ul><ul><li>If displaced, ORIF with longer immobilization period and early ROM if tolerated </li></ul></ul>
    30. 30. Ulnar Fractures <ul><li>Coronoid process fracture </li></ul><ul><li>May be associated with posterior elbow dislocation </li></ul>
    31. 31. Radial Fractures <ul><li>Radial head fracture classifications (Mason) </li></ul><ul><ul><li>Type I: nondisplaced </li></ul></ul><ul><ul><li>Type II: fracture with displacement, depression or angulation </li></ul></ul><ul><ul><li>Type III: comminuted fracture of head </li></ul></ul><ul><ul><li>Type IV: comminuted fracture associated with elbow dislocation </li></ul></ul>
    32. 32. Olecranon Bursitis <ul><li>Typically due to direct trauma </li></ul><ul><li>Usually easily treated with rest, modalities compression, and NSAIDs </li></ul><ul><li>If persists, may be aspirated – risk of infection </li></ul>